RAPID ACCESS CLINIC CONSULTATION REQUEST FORM

1 45 Mill Street Toronto, Ontario M5A 3R6 Tel: 416 869 DERM (3376) Fax: 416 365 SKIN (7546) RAPID ACCESS CLINIC - CONSULTATION REQUEST form This Dermatology RAPID ACCESS CLINIC (RAC) combines the best of walk-in clinics and specialty care provided by Dermatologists certified by the Royal College of Physicians of Canada. Referring Provider: OHIP Billing #: Office Phone: Fax: Family Doctor: Family Doctor s Phone: Patient Name: Health Card #: Version Code: DOB (D-M-Y): Address: Phone: Alternate: Email: Reason for Referral: Additional Info: RAC HOURS OF OPERATION : MONDAY FRIDAY 8:00 AM TO 11:00 AM Improved ACCESS with reduced wait times All dermatological conditions seen, not just urgent cases Wound care is outside of our scope of practice Patients will be seen as soon as next business day NO appointment necessary MUST be referred Wait times will vary based on daily volume All consultations by FRCPC Dermatologists Collaborative Care Hours of RAC are subject to change.

2 Visit for updated information. Please fax referral to 416-365-7546 or email to and give copy to patient. Confirmation or booked appointment not required. Patients can visit CLINIC as soon as the next business day during RAC hours (see below). AvantDerm is more than just a Dermatology CLINIC . We are located in the heart of the vibrant Distillery District, just steps to live theatres, trendy galleries, award-winning restaurants, boutiques and cafes. Our breathtaking architectural features and chic interior embody style and sophistication. Inspired by our artisan neighbours, our CLINIC combines state-of-the art medical technology with classic distillery design elements. It is well worth arriving early to take a stroll down the gallery-lined cobblestone streets, or to enjoy a coffee at a local caf . We are easily accessible by both car and public transportation.

3 D r i vi n g D i r e c t i o n s From Gardiner Expressway take Jarvis St. Exit North. Turn right on Front St. to Parliament St., then right on Parliament St. to Mill St. Turn left on Mill St. Pa r ki n g Ample parking available on street, 3 adjacent outdoor lots and underground lot directly below CLINIC . Su b wa y From Union Station take Bus 72A and exit at Mill St. directly outside of CLINIC or, walk 15 minutes from Union Station to our front door. St r e e t c a r Take King Streetcar 504 to Parliament St. and walk two blocks south to Mill St. GO T r a n s i t Take GO Transit to Union Station and connect to subway or streetcar routes.